S207 Week 4 23 January 2007 Marx recap  rise of capitalism  feudalism inexorably leads to capitalism, and capitalism in turn

inexorably sows the seeds of its own downfall  classes  manufacture of consent – those being dominated have to accept the terms of their domination. you can trace this idea back to Marx, who talks about hegemonic domination (though it was theorists after who crystallized the notion of hegemony). but Marx generated the idea that the ruling ideas of an epoch are the ideas of a ruling class. where you are situated in the social order gives rise to your ideas. according to Marx, social position drives ideas, not the other way around.  Tania: role of religion. what role does it have in a capitalist mode of production?  surplus value  exploitation – reducing the cost of the raw materials and/or extracting the most from the laborer. structure the production process so you get more and more labor from each worker  alienation  commodification  commodity fetishism. Navarro talks about our consumptive drive to consume commodities. in Marx’s view, that comes from our alienation from our labor. we can’t externalize our human nature what we produce, so we end up seeking fulfillment in the accumulation of commodities  representation and manifestation of certain relations between workers and capitalists was there a crisis in medicine? what accounted for it? how was it perceived? Freidson recap medicine acquired (via persuasion) the patronage of the elite and became a profession. consent had to be manufactured. reliance on political strategies; acquisition of legislative controls over who would be allowed into the profession in somewhat opposition to Parsons, who took medicine’s collective orientation for granted Starr recap transformation of American medicine to what it is (was) physicians were able to acquire gatekeeper status over certain portions of the economic sector of medicine, so they were able to shape hospitals away from being a potential competitor or employ, and shape the interests of hospitals to coincide with their own Brown John: he places a much more central role on foundations (funded by the money from industrial capitalists)

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emphasis on scientific method and rationality Janet: all of the authors do point to the notion of scientific medicine – that medicine could be scientized.. formalized, rationalized using the scientific method. nobody disputes the primary importance of that move, of attaching the rationalization of medicine and professional autonomy to the wagon of scientized medicine. what people do differ about is the degree to which they question what is scientific medicine, and whose interests does it promote? medicine, for its part, really worked to try to make a claim for technical competence, for esoteric skills, for possessing a body of knowledge that not everyone would be able to access or accumulate on their own. a shift from more specialized forms of expertise. Starr attributes part of the rise of American medicine to increasing dependence on expert knowledge. so he does talk about the process of legitimation, but he doesn’t question the entity of scientific knowledge. Beth: Starr doesn’t problematize anything. Navarro John: medicine plays an important role in legitimizing the social relations Janet: it’s not neutral, it’s not apolitical, it’s not objective, and in fact, all those words (neutrality, objectivity) are in fact ways in which science is in fact acting as an ideological tool Jonathan: Navarro sees physicians as the puppets of capitalists (Janet: instruments, organs of the capitalist state) Janet: analysis of American society and the American economic system, of which medicine is simply a reflection of what’s going on in the wider society. it’s ludicrous and empirically incorrect to analyze medicine unto itself. you have to understand what’s going on in wider society. whereas a lot of other theorists do look at medicine unto itself; they may make generalizations (Freidson re: professions at large), but few have concepts of the societal transformation that Navarro and other Marxists do. what is the specific cast that Navarro gives to talking about legitimization?  in Freidson, all he says re: political strategy and MD’s relation to the state is: political patronage by the ruling class in order to get the legislative protection they needed to maintain their special status.  whereas Navarro is far more incisive and thorough in his examinations of what that relationship is.  Krista: he talks about racial and ethnic divisions in medicine. Flexnerian medical knowledge. p. 28 – “Flexnerian medical knowledge reflects bourgeoisie constructs”  Janet: Parsons talked about affective neutrality and collective orientation (toward universal good). Navarro brings a very fundamental critique – that’s not what’s happening at all. in fact there’s a whole economic infrastructure that shows science and medicine are furthering the very particular interests of the dominant ruling class what are some of the other ways that Navarro talks about science and scientific medicine serving as an ideology?  Elena: the drive is to maintain the status quo in power relations  Krista: only certain people get to have the luxury of having a healthy lifestyle

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Janet: capitalism creates conditions under which people get sick, and are disproportionately exposed to conditions that cause sickness.. and particular style of treatment of those conditions. workers who are within the capitalist mode of production are pretty much forced (b/c there is no real alternative for survival) to subject themselves to exploitation. there is no system outside the capitalist system. they have to consume commodities and work in conditions that make them sick.. and that furthers the interests of the capitalist bourgeoisie.  Tony: health is instrument of social control. scientific knowledge dominated by bourgeoisie. medical journals sponsored by drug companies. Navarro characterizes science as a social relation. what does that mean?  Elena: names of viruses can have political implications.  John: science the creation of the bourgeoisie, contraposed to religion – way for bourgeoisie to assert itself over knowledge previously in the domain of the clergy  Janet: it’s not the result of evolutionary history that’s naturally led things to be the way they are. there are always interests behind it. Navarro says the same thing about science. it’s a social relation, reflects a social relation.. it’s embedded in a social relation. science captures certain ideas about who has power, who has power to name things, to pathologize things. knowledge will always be tied/encapsulated in/embedded in social relations between interested parties.  Krista: p. 169 – social class appears as one more variable. you can’t just add socioeconomic variables to disease and make it classless  Janet: he’s talking about a different order of causality. it’s not just risk factors A, B, C, D. it’s a different way of thinking about multicausality that leads one person to be sick and another person not to be. Navarro is saying social relations are causally precedent/preceding all these other factors we’re looking at. scientific medicine able to reproduce power relations and act as an ideological force.  the dominant ideology reproduces itself (what is a disease?), its methods (how are we to know what is a disease?) and the relations the inquirer has in the overall process of production (problematizing the role of physicians/medical scientists in the larger social structure).  John: it presents itself as value-free in the process. which is another way of legitimizing.  Janet: science becomes that magic word to translate a value-laden knowledge into a value-free one.  John: AIDS in 1980s  Erica: NYT magazine – women’s traumatic feelings after abortion  Krista: you can only judge the science of a time based on the time in which it was conceived. the science of a given time was science  Janet: he’s saying that calling something scientific or a scientific knowledge is in itself a political move. it’s not like the universe of questions we can ask is completely open. science has to choose its direction, what questions it will address. AIDS so highly politicized, it would be hard to argue that it wasn’t. the science, the activities people were using to try to figure out what was going on epidemiologically was aimed at just this one part of the domain of universal possibilities. that selection in itself was a political move. why not all these other possibilities? what are the consequences for 

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different classes of people situated in different social positions? Navarro and others talking about science as political activity, as socially constructed. Jonathan: science has only recently come under scrutiny Janet: political moves. labeling something as objective vs. subjective, science vs. lay. those are all very political, ideological moves. what’s anecdotal vs. data-driven. these are all steps in the legitimation of a particular mode of capitalist production. and here’s how medicine and medical science play into that.

who thinks things have changed the least?  Navarro?  John: something functionalist about Starr.  Elena: lot of rage among nurses.  Cindy: what has changed is how we define disease. rage prevalent among any marginalized people.  Jonathan: technology as interfering with professional autonomy of physicians (Brown) what does Freidson say is going on within medicine?  Beth: formalization of professional control  Janet: it’s not proletarianization. doctors not going to become wage laborers in service of capital. rather, what will happen is within profession itself, there’s going to be increasing stratification, which will become far more overt; more formal methods of internal control. the people controlling the profession are professionals themselves, many now in administrative positions (physicians controlling other physicians). whose interests will they become beholden to? when he was observing things (1994), for the most part, yes, things have changed, but the key kernel (professional autonomy) of what makes a profession has not changed.  proletarianization = a code for Marxist perspective where does Brown think the crisis of medicine is coming from?  John: Starr sees irony that rise in expenditures in 1970s led to incentives for privatization, etc.  Janet: previously unreimbursed services (Medicare, Medicaid) were reimbursed, leading to incentive for privatization  Beth: physicians set rules of game -> stakes so high that others wanted to get in the game (physicians sowed seeds of their own undoing)  Janet: Starr talks about how doctors early on (when trying to build professional autonomy) were so focused on making sure government not regulating any content of their work, became their eventual undoing – so much focus on fighting government regulation, that by the time the corporations became so lucrative / privatization got involved, doctors couldn’t stop it. Starr does talk about corporatization, but he’s not a Marxist. those are the trends he attributes to the fall of medicine.  Jonathan: federal government subsidizing hip replacements -> increase in hospitals focusing on hip replacements, and privatized industry surrounding it  Janet: Brown talks about the crucial role of foundations in providing financing to systematize medicine. so now the very basis of modern medicine is science and technology – a highly technologized medicine. inflationary tendencies – need to keep up,

enormous amounts of capital. for the most part, in their history of professional medicine, doctors were able to shape the interests of hospitals ot reflect their own. but their ultimate reliance on insurance companies hospital chains, big pharma (those with capital to promote this brand of medicine) sowed the seeds for fall of medicine.  unintended consequences -> declining autonomy of physicians. Navarro and his critiques of Starr and his own theories of what accounted for decline of / crisis in American medicine  he talks about 2 different crises.  p. 21 – the crisis of Western contemporary capitalism.  disagreeing with ideologies of industrialism (attributing fall of medicine to industrialization of medicine)  crises of legitimation and capital accumulation. crisis of medicine = part and parcel of that broader crisis.  Marx talks about capitalist mode of production inexorably having to face crises of legitimation and capital accumulation.  crisis of legitimation = questioning of how effective is medicine anyway? capitalism is producing disease – what is medicine doing about it? medicine can take care of disease, but can’t cure them.  crisis of capital accumulation  Tania: medical care penetrating different social services  Janet: very basis of this economic and social relations of production, if it’s going to be capitalist, it has to produce commodities to survive. medicine = business of producing commodities. once that happens, you have fertile ground for corporations and private interests to invade the market. that leads to things like increased division of labor (attempt to rationalize the process of producing medical commodities), etc. every worker (physician) ends up working on their own little piece of the process, and they become distanced from the overall endeavor. which leads to alienation. and eventually, Navarro says, to the proletarianization of physicians. (commodification = widgetification = McDonald’sization = Taylorization) theorists generally agree re: primacy of a scientific notion of medicine. right to control your own work. way in which they talk about those things, and whether they take them at face value, that these theorists differ. they make similar observations re: what is happening, but their story of why/how differs. McKinlay and Marceau  where would you array them?  they definitely think there’s a crisis.  what did they think the implications were for the profession of medicine?  Beth: before it was a mark of the decline of medicine, but now it’s a shortage in physicians.. so does that mean medicine will be on the rise again?  Jonathan: lay access to information. patients can now, to a greater extent, shop around for providers. p. 202

Janet: if that plays itself out, that’s the kind of change Freidson would really see as spelling the real decline of professional autonomy. it’s not necessarily these larger economic changes – it’s this that strikes at the root of professional autonomy. he talks about working class science. the question becomes, does it count as science? what would it take for it to count as science? it would involve a fundamental reranking of who the ranks of scientists are. it would require some fundamental changes. Erica: doctors who refuse insurance, separating themselves from legitimating structures

Freidson  p. 134 – knowledge gap  p. 202  knowledge gap between professionals and layperson will never go away, b/c the body of knowledge medicine needs/draws from is always expanding a lot of the authors we’ve been reading talk about change in societal expectations about what public wants and desires. things becoming increasingly uncertain. it seems like there are so many domains of life where we need expertise and technical knowledge. what does the public want from medicine and medical professionals?  integrated care  Erica: people used to want choices; now they want answers – at the same time that professionals are growing more reluctant to give answers with any certainty (due to litigation, etc.)  Janet: not a coincidence that issues of the ideal of patient autonomy, the fall of medicine, whether we want professionalization, etc. are all coming up at the same time